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tv   HHS Secretary Azar Testifies on 2020 Budget Request  CSPAN  April 10, 2019 7:46am-9:45am EDT

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landscape has certainly changed. youtube stars are a thing. but the big idea is more relevant today than ever. no government money supports c-span. it is public -- it is at as a public service. c-span is your unfiltered view of government so you can make up your own mind. >> the health and human services secretary testify at a senate hearing. they will come to order.
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the secretary a's are think you for being here again this morning. for the efforts to work together that could always be better. i think we are about to get you stepped up to a point that that will no longer be the excuse. we will think of what comes as the next reasonersoso a that ths not working the way it should. i wanted to encourage to continue it's a difficult budget for us to talk about. we will see what we have to do here. the budget control act has impact on thiss and in the case of the budget you had been asked to submit their there is a reduction of 14% it will require an overall reduction in the non- defense discretionary spending.
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president trump did not sign it., most of us who are here. there is some shared responsibility in where that decision has led us. there will be a number off concerns that i imagine you have to share about what this budget ask for. we've made a top priority in the years that i had been chairman of this committee ensuring that medical research has the resources it needs at this particular type of real breakthrough potential to do what it does in a way that saves lives. improves lives and friendly benefits tax payers as we find more solutions if we could find a way to identify
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alzheimer's and delayed onset by five years we had cut the projected cost by a third between now and 200050. the cuts that you are proposing for an nih would be an overall cut of 12.6 percent in research or $5 million i am sure that as i can happen. but for that not to happen we have to have a number to work with that you don't have to work with yet. we are not going to eliminate the funding that provides 6 million households with heating and cooling assistance. this cuts resources with a lot ofeo people from medical professions and behavioral health and pediatric dentistry
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and we are not likely to do any of those things. i understand you to make difficult decisions here. i do appreciate the two new initiatives that you propose i will be supportive. one to eliminate in phase one of the ten year plan. missouri is one of those. with additional resources and expertise i'm pleased to see that that is a new proposal as is the new pediatric cancer program to provide $5 million over the next decade to launch a major data project on childhood cancer. that runs pretty dramatically
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i do think it gives us the opportunity to look even closer at pediatric cancer and factor that in as we continue to improve funding. in addition to these new ogprograms i believe that mental health treatment needs to be treated as any other health issue the budget request includes funding. for the behavioral health clinics missouri is one of the eight pilot states. treating behavioral health like all other health the have of barnes jewish hospital just told me last week. i can't treat a person's diabetes until their schizophrenia is under control.nd
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you actually save more money on the other health care costs then you spent doing the right thing and behavioral health. it is will reflected in this request. according to the council of economic advisers. the total economic cost in 2017 according to the missouri hospital association this estimate suggests the epidemic cost nearly $1.6 billion every day.
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the past four years this subcommittee has increased funding to combat the epidemic by more than 3.5 billion dollars. and we've have a great bipartisan leadership on this. on both sides of where i am sitting they have understandat -- understood how this impacts their state. i appreciate what you have to do to try to prioritize it. i'm glad you're here today. i'm glad you bring all of the expertise inability. i like to turn to my partner here. >> thank you very much. people are across the country made pretty clear last november that they wanted to fight for their health care and healthcare and make sure that familiess get the cure that they need. that means fighting for
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protections. it means fighting to bring down the skyrocketing health care costs. they keep our communities safe. and address crisis like these. it means fighting and investments in research. d instead of fighting to defend their fighting in court to help take healthcare away. instead of fighting to bring those costs down. he is fighting in court against protections for over 130 million people with pre-existing conditions. for bringing it back in you your lifetime caps on benefits. and they get their insurance through their own job. and for letting them offer plans that don't cover
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essential services. in president trump his budget is cut from that same cost. it goes right over the concerns of families with proposals for families to make it harder for people to get ou wcare. slashing it by 14%. i always say a budget is a reflection of your values. this budget tells a very different story about heesident trump's healthcare priorities and empty promises. he would fight for people's healthcare. they would be the party of healthcare. president trump is continuing to push for harmful policies that would weaken patient protections take coverage away from people and put needed
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input needed healthcare further out of reach. this includes trump care which the budget office estimates will take tens of millions of people off their health insurance. the budget actually fans the flames. they would make it far worse. and repealing medicaid expansions. medicaid is the largest source of encouragement -- insurance coverage covering more than 40% of people with hiv and care. in the 37 states that expanded medicaid show how it can play an important role in addressing the opioid crisis as well. in some of these states as many as four out of five people receiving treatment for opioid addictionsdi are insured by medicaid. they also play a very important role the trump
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administration proposes cutting its budget by attend. even admitted an alarming outbreak in proposes cutting efforts to combat anti- biotic pathogens. and a merging of the effects just diseases by $103 million despite the world health organization one of the biggest threats to global health. this is a small step forward. and a marathon sprint back. i do applaud the call. for pediatric cancer research.po
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cutting medical research by 13% as he proposed. and treatments and cures for every other kind of cancer. in at a time when our nation is facing a health professional shortage is proposing to cut almost $800 million from healthcare workforce training funds that support assistance. this budget also continues thear harmful trend of putting ideology over women's health and reproductionh freedom. it is just one of the many alarming steps backwards. her women's healthcare from this administration. a recent announcement stripping title x familyua
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funds. from the planned parenthood affiliates. despite their proven record of helping millions of people struggling to make ends meet. get birth control, cancer screenings and other basic health services. another example is administration they interfere with patient's abilities to learn about their full range of reap productive care options with the providers that they trust. once again the trump administration proposesim the safety net programs to millions of vulnerable families. like the low income vulnerablele which helps them afford heating and cooling. in the community services block land which gives state resources to address the challenge of poverty. and eliminating funding for preschool development grants which provide high-quality preschool to tens of thousands of families.
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we are facing at child care crisis. they struggle every day to find and pay for high-quality programs. this budget continues to show disregard for families this budget proposes a gimmicky 2 billion-dollar contingency fund on the mandatory side. every child is will cared for. but i had been deeplypp disappointed. to attempting to undermine protections from migrant children. and i had been frustrated with your department.
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sharing information with the part the department of homeland security. it relying h heavily on unlicensed temporary statistics. in the former director was personally interfering. finally mister secretary. ..ry ..
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it is inaccurate to claim the budget control act requires the president to submit his budget at sequestration levels. in fact, just two years ago president trump's budget proposed an increase to the caps for defense spending. i hopese you don't rely on that excuse for decisions in this budget.. thank you very much, mr. chairm. >> thank you, senator murray. secretaryta azar, you and i tald about the -- i'm sorry, we want your -- i'm sorry. i'm soo eager, i've so many questions i want to ask. maybe you want to wait her opening statement but go ahead with your opening statement. >> thank you very much chairman blunt and ranking member murray. thank you provided me to discuss the president's budget for fiscal year 2020. it's an artist of the year since elastic before this committee leading the department of health and human services. the men women of hhs have delivered remarkable results during that time including record new and generic drug
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approvals, new affordable health insurance options and signs that the trade and drug overdose deathshs is beginning to flatten and decline. the budget proposes $87.1 billion in fy $2020 in fy '20 20 discretion are spending for hhs while movingt toward our vision for for a healthcare system that puts american patients first. it's important to note hhs had the largest discretionary budget of any non-defense department in 2018, which means staying within the caps set by caucuses require difficult choices that of sure many will find quite hard. i know members of this committee have delivered strong investments in our discretionary budget in the past, especially at the national institutes of health and the want to be clear hhs appreciates this work over the years. today i want to highlight how the president's budget supports a number of important goals for hhs. first, the budget proposes reforms to deliver americans truly patient centered
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affordable care.er the budget would empower states to create personalized healthcare options that put you as the american patient in control and ensure you are treated like a human being and not like a number. flexibilities in the budget would make thisca possible while promoting fiscal responsibility and maintaining protection for people with pre-existing conditions. second, the budget strengthens medicare to help secure our promise to america's seniors. the budget extends theic solveny of the medicare trust fund for eight years while the programs budget will still grow at 6.9% annual rate. in three major ways the budget lowers cost for seniors and tackles special interest that are currently taking advantage of the medicare program. first, we proposed changes to discourage hospitals from acquiring smaller practices just to charge medicare more. second, we addressed overpayments to post acute care providers. and third, we'll take on drug
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companies that are profiting off of seniors and medicare through a historic modernization of medicare part d, we will lower seniors out-of-pocket costs and create incentives to lower list prices. i believe there are many areas of common ground on drug pricing we can work together to pass bipartisan legislation to help people. the efforts we have proposed around taking on special interest in the medicare program are so sensible and bipartisan in fact, that even the "new york times" editorial board praised these ideas last week. we also protect seniors by transferring funding for graduate medical education and uncompensated care from medicare to the general treasury fund so that all taxpayers, not just our seniors, share these important costs. finally, the budget fully supports our five-point strategy for the opioid epidemic better access to prevention, treatment and recovery services, better targeting the availability of overdose reversing drugs, better
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data on epidemic, that her research on paint at addiction, andd better pain management practices. the budget builds on appropriations made by this committee and provides $4.8 billion towards these efforts including $1 billion state opioid response program which we focus on access medication-assisted treatment, behavioral support, and recovery services. the budgetbl investment of the public health priorities including fighting infectious disease at home and abroad. it proposes $291 million in new funding for the first year of president trump's plan to use the effective treatment of prevention tools that we have today to end the hiv epidemic in americao by 2030. hhs also meant the children of the public health challenges including the current epidemic of teen use of e-cigarettes. in fact, i'm pleased to announce that today the fda's issuing warning letters to companies for making, selling, or distributing liquids used for e-cigarettes
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that misleading labeling or advertising that resembles prescription cough syrups. the trump administration supports a comprehensive, balanced policy approach to regulating e-cigarettes, closing the on ramp for kids become addicted to nicotine while allowing for the promise of an offramp for adult smokers of combustible tobacco products. this year's budget will advance american healthcaree help delivr on the promises we make to the american people and i look forward to working with this committee honor priorities and i look forward to your questions today. thank you very much. >> thank you. now we get to this questions. i'm hopeful that we can get through most of her questions by the vote and leave sometime shortly after 11:45, that if we don't i'll come back and there would be a second run a question for anybody who wants its i would ask everybody including a to stick with a time limit. momt
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about the new liver allocation policy, the solid organ allocation policy, something that senator moran and i have been very interested in. we had one meeting with the oregon transplant procurement network -- organ transplant procurement network group and, frankly, our view of that meeting was very different than a what they finally did. both the university of kansas and washington university are really among the leading stakeholders in this in terms of the transplants that they're part of. i guesses the problem is that states in the midwest, states in the south, states that have lots of small communities tend to be much greater organ donors and, obviously, as long as we had a regional view of this, that was a benefit to their neighbors. there's been a dramatic decrease in availability of lung and
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liver transplants at barnes hospital at least since the new policy went into effect. and as my question, i think there'll certainly be a lawsuit filed here. will you commit today that you'll ask optn, the transplant group, not to move forward with this controversial policy until that lawsuit has been dealt with? >> well, mr. chairman, i am concerned about the liver allocation policy issue, as you raised. frankly, any transplant organ allocation policy issues are quite difficult politically and as a matter of public health. and i actually, i received the letter from you and many others about the most recent organ -- the liver transplantation allocation policies out of optm, and requested of them to think of them and to insure
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especially -- i believe it was, was it the kansas and missouri providers that we wanted to insure especially that comments that came in at the last minute or perhaps came in late were fully considered by optm. we recently received a letter back in response to my challenge to them, which i believe your staff has access to. basically, they said they went through the procedures, they considered all of the comments, and they remain steadfast in their conclusion regarding the science and technical aspects of the allocation decision they made. i do believe my cards are played out here. congress deliberately set up the optm system to keep people like me from dictating the policy allocations, but i'm happy to work with the committee on any other solutions here to look at and insure that the fair and scientificically valid treatment has been given here. >> well, i would think one of the reasons the old system worked was that people were more encouraged to be donors if they
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believed that people in their community would benefit from that. on liver transplants under the new policy, we think there'd be 32% fewer transplants in missouri. i think barnes hospital's number four or five in the country in france plants, and they have told me -- transplants, and they have told me since this started they're now having to send teams of doctors across the country to have, to get organs that would have been available under the old policy locally. i think it's further complicated and added expense and precious time to the system. we're going to continue to watch that. let me is ask one more question here on a big issue, and that's your role in providing security and taking care of unaccompanied children. you have nothing to do with
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border security, but you wind up with great responsibility. would you talk about how that's changed in the last few months? >> absolutely, mr. chairman. we're in a tremendous crisis at the border right now. we are getting 300-350 unaccompanied alien children crossing the border and referred to hhs every single day right now. these are 10, 12,13, 15-year-old kids coming across the border by themselves. and this is -- these are historic levels for us. that's a 97% increase in february from the previous year february. it's just not sustainable at9 this rate. i know the ranking member raised in her opening statement concern about temporary influx facilities. i will work with this committee to take care of the children appropriately, any ideas of how to insure we're doing that well, i would love to enhance our fixed permanent capacity. it's cheaper, it's more economical. we've been working on that.
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it's slow to do. you understand government contracting around leasing is slow. we need help. we need help. and at this rate, the funding even for this year will not be satisfactory, and i want to be transparent with this committee in particular about that. we are working with omb on what those total funding needs could be at the current rate, but it would exceed where we are even with the transfer and reframing that i notified the committee about. this is just, it's beyond belief, the level of children that are coming across the border right now. >> [inaudible] in your case the unaccompanied children -- >> these are unaccompanied children. these are kids just coming across, they don't have a parent with them, they're coming by themselves. >> all right. i have more questions on this, but i'm going to stick with my time restraint. i have a feeling they'll bed asked -- they'll be asked by others. senator murray. >> thank you, mr. chairman. mr. secretary, despite continued assertions that your budget
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guarantees affordable health care and protects people with pre-existing conditions, the fact is that the administration is doing everything it can to actually sabotage health care, and this budget appears to be just more of the same. this budget continues to push harmful policies that undermine if health care for millions of people across the country. your budget calls for repealing and replacing the acc with the failed trumpcare bill which was rejected last congress, and in his clearest message yet to patients and families that he sees their health care coverage as nothing more than some kind of political football, last week president trump sided with the ruling that all of the aca should be struck down. all of it. now, according to reports, you initially opposed president trump on that and issued a statement of support. so i wanted to ask you today, did you initially object to the president's decision to side with the texas court? because you know the impact that this would have, it'd be
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devastating for so many families? >> as you can appreciate, the advice of a cabinet member to the president of the united states is highly confidential, and it wouldn't be appropriate for me to comment on that. what i would say is the position the administration took in the affordable care act litigation is an appropriate decision supporting a district court's decision. reasonable minds can differ on this question of legal issues. this is not our policy position. that is a legal conclusion about the aca, and that litigation -- which we did not bring, we are a party, i'm the party in the litigation -- but we want to protect pre-existing conditions. if the litigation ends up in that position, we want to work with you to secure better care for people and make sure all the types of issues you've raised are taken care of in any kind of new legislation. >> well, let me just ask you, as secretary of health, to you green -- do you agree that if this ruling is upheld as the administration is arguing for, it will result in tens of millions of people losing their
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coverage and allow insurers to discriminate against people with pre-existing conditions if it's upheld? >> well, the burden would be on us to work together to actually come up with a -- >> that's not the question. the question is if the court dose through with the ruling as -- goes through with the ruling as you have requested them to, will it result? >> well, you wouldn't have medicaid expansion, and you wouldn't have the exchange -- >> pre-existing -- >> unless you can come up with a better system that we think delivers better care -- >> i've heard that before. it would mean that people with pre-existing conditions. >> the president will never agree to any legislation that -- >> i'm not asking about legislation, i'm asking about the court decision. >> a legal, a legal interpretation of a court case is not a policy position about what we want to have happen for people with pre-existing conditions. >> well -- >> we're going to fight for people with pre-existing conditions under all circumstances, but a legal judgment filed by the justice department is different than a policy position to work with you
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to protect people with pre-ex. >> okay. well, it's pretty clear if that, if the administration goes after this in court and wins, people will lose their pre-existing conditions at that point. so let me, let me just go on. i wanted to ask you about title x, and as you know, i am really concerned about this administration's constant efforts to undermine the historically bipartisan title x family planning program. it's the only federal program dedicated to contraceptive health care and family planning services and actually helps four million people annually get services like cancer screenings, contraception, crucial preventive health is services. your title x domestic gag rule will take effect very soon, and barring -- it will bar providers from talking to their patients about all the family planning options. the american medical association has actually called that rule, quote: a violation of patient's
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rights under the code of medical ethics, unquote. and they've actually joined planned parenthood to fight that in court. you also announced the title x grant recipients for 2019, dropped five planned parenthood affiliates, make it harder for tense of thousands of women get the care they need and awarded funding to an ideologically-driven family planning, your intent to authorize the offices that administer title x and teen pregnancy. if you could answer yes or no, i wanted to ask you, is birth control an evidence-based family planning option? >> we support the full range of family planning. that's why we fully funded and kept it flat, kept the title x flat funding even as we cut other part obviously the budget. so we do support access to contraception and birth control and the full range of family planning options. >> and you believe birth control
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is part of -- >> it's part of the title x program, and we support that. >> so the one entity that you're referring to, actually, part of its grant application is required -- there are going to be seven federally-qualified health centers. these are always done as a program with a grantee and subgrantees, so they have to offer across the program the full range of family planning alternatives -- >> including birth control. >> yes. so they will have other providers in there, the seven -- >> so it'll make it harder for women to get pushed around. i get it. all right. my time is up. >> thank you, senator murray. senator al zapper. >> thank you -- alexander. >> thank you, mr. chairman. welcome, mr. secretary. let me first pass a compliment to senator blunt and senator murray, the ranking member, and other members of the subcommittee for three consecutive years of significant -- four consecutive years of significant increases of funding for the national
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institutes of health. we see the results of that everywhere, and i fully support it, and i thank you for your leadership, senator murray, senator durbin and you have been consistent supporters of that. second, to the president and to you, i'm proud of the initiative that seeks to reduce hiv infections by 7 a 5% in -- 75% in the next five years, 90% in the next ten years. i hope you will focus especially on those parts of the country where that's a special problem. african-americans account for 43 % of hiv diagnosis. in 2016 more than 84% of the people in memphis with hiv were african-american and of estimate new hiv diagnoses in temperature, more than 25% -- in tennessee, more than 25% were in memphis alone. i want to call to your attention the medicare area wage index which i won't ask you a question
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about, but that's continuing to be a reason why hospitals especially in rural tennessee and other parts of rural america close, because of the unfairness of that index. now, mr. secretary, i heard the question by the senator from washington about the affordable care act. i think it's a pretty farfetched case, in my opinion, but i'm not the judge. i'm pretty sure that if there were any decision that resulted in the affordable care act being overturned, that the court would stay the effect of the decision giving congress and the president time to do whatever they wanted to do. let me ask you this question. have you made any changes in the way you are administering the affordable care act as a result of the department of justice's position on this litigation? >> we have and will not make any changes to how we ad more the affordable care act in light of
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the litigation. it could be a year, two years before we get any final ruling by an ultimate, final court of jurisdiction. i have instructed my team, my organization we continue to implement the affordable care act faithfully and fully across the board without regard to litigation positions taken by the administration in court. >> so whether you like it or not, you recognize it's the law. >> absolutely. >> on a separate question, the committee that i'm chairman of and senator murray's the ranking member, the health committee, have been working with the finance committee, senator grassley and wyden, for the last several months to see if we could identify a series of steps to reduce health care costs. testimony before our committee is that up to half of health care costs are unnecessary. we're working on that the same way we worked on opioids which means democrats and republicans working together, various committees working together,
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staffs working together. so far so good. our goal in the health committee is to see if we can produce a recommendation, a mark-up for the full senate by june or july. are you and the administration willing to work with us and support our efforts to address these issues like surprise medical bill, prescription drugs, direct primary care, transparency, rebates, other issues? if we're going to work in a bipartisan way, is the administration willing to support our efforts to get a result in this way? >> we are fully supportive of the efforts of you, senator murray, chairman grassley, senator wyden working together on a bipartisan basis across all of those issues. >> on opioids, president trump asked the president of china to make all forms of ethanol illegal, and china has
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announced -- in china -- and china has announced that it will do that starting may the 1st. i want to congratulate you and the president for that and thank the officials of china for that, because our drug enforcement agency has told us that one way or the other most of the fentanyl that comes into the united states starts in china. i don't have time for you to answer a question, but as we think about opioids, i hope that you will keep an eye on the effect it's having on people with pain while we're getting rid of opioids that are used inappropriately. we wanted to make sure -- we want the make sure they are used appropriately by doctors and the cdc guideline, about which there'll be a report in may and the fda report in august, should be seen as advice and guidelines leaving the decisions in the hands of individual doctors, and
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i hope you'll help us to that. thank you, mr. chairman. >> thank you, senator al alexander. and i want to say having you and senator murray on things like the health care issues and moving forward with nih research makes a real difference, having both of you here who also have the authorizing committee and your leaderships really matter particularly on what we've been able to do at nih. nobody's been more involved in that than during by. senator -- senator durbin. senator durbin? and congratulations to you and senator murray. four years of consistent growth at nih is saving lives. the president's recommendation of making a cut in medical research, i believe, will be roundly dismissed by both political parties, and i hope that that's the outcome soon. i thank you all, including senator alexander. so, mr. secretary, i have so many questions, so little time, as they say. let me go to this unaccompanied children issue for a minute. when i asked the inspector
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general to investigate the zero tolerance policy of the trump administration which forcibly removed over 2800 children from their parents when they came to the united states, we were told that, in fact, the public announcement of this program actually postdated the initiation by as much as a year that there could have been thousands that a had not been disclosed prior to the announcement. were -- when did you first become aware, mr. secretary, of the president's zero tolerance policy? >> so i became aware of the attorney general's zero tolerance initiative basically when he announced it in the public. i learned of it in the media in april when the zero tolerance was announced at that point. then subsequently as we have been going through this, i believe in the summer or late summer, maybe it actually might have each been through the inspector general's work that
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you asked for, learned of some of the previous piloting. >> how many children were affect by this piloting or demonstration effort? >> well, as the inspector general said, there was a surmise there only of numbers. there was no -- the inspector general just said there could be a couple of thousand but didn't know how many in that case. >> did you play any role in crafting this policy of zero tolerance? >> no. how could i if i learned about it in april when it was announced? this. >> so let me ask you about unaccompanied children now. you say there's an inflow of 300-350 unaccompanied children a day coming into the system. your web site says that you have facilities for placement of up to 14,000 children and currently some 12,000 are placed in your facilities. is that correct? >> so as of this morning we have 12,340 children in our care. we've got 428 available beds with another 114 beds summit
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to -- could be available, but usually it's an issue of getting adequate staff thing. we are very tight right now, senator. >> understood. and what is the outflow of children who are actually sent to families or placed outside your facilities? >> so our discharge rate has been quite high, we've really been prioritizing and working on that. our discharge rate on a 30-day reference has been 2.0 children per 100 children on discharge, and on the seven-day we're actually 2.4 children per 100. i think if, as i've looked in the last couple of weeks, we are essentially adding almost 70-80 children per day just because of the inflow and outflow rates. >> the net -- >> net, exactly. >> so is it true, as we've been reading, that these children are primarily coming from three countries? >> that's absolutely correct. we get a -- it's guatemala, el
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salvador and honduras. one of the particular challenges lately has been we've been getting -- it's a lot easier for us to place children out where they have actually one parent here in the united states or a close relative because we can make that a faster process. it's a check on them. some of the children, we've been getting an increasing mix of guatemalan male teenagers who have no family connections here. those become extremely difficult for us to try to place out. >> i've, i understand that part of it. it is interesting to note that these children are coming from three countries. not nicaragua, not costa rica, not mexico, but these three countries that the president now wants do cut off all foreign aid to these countries believing, in miss hind -- in his mind, that is going to solve the problem. i think it'll make it worse. i think it's important to note that the administration eliminated the program where children could go through the screening in home country at the u.s. embassy and consulate.
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and now many of these families in their desperation have no other recourse to test their status than come to the border of the united states and present themselves. so wouldn't you believe that it would be helpful if we had a system restored as it was under the obama administration for screening that begins in country? >> senator, i am not an immigration law expert. i had not known about that country, in country actually seems consistent with the discussions that aye heard from secretary nielsen about the desire to have asylum claims adjudicated, i'd be happy to -- >> please do. i hope you will raise it. >> i'll look into it. >> i have a lot of really good questions on prescription drug pricing -- >> i hope we can keep working together, you and i, on -- and really appreciate your support on direct to consumer add a advertising. >> listing the price is favored by 88% of the american people. >> yep. >> thank you for, on a
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regulatory basis, for moving on this. we did include it in the appropriation bill in the last round -- >> we got close. >> we got close. it was killed in the conference in the house, but i'm hoping and praying that senator blunt and others will stand behind restoring that. >> i'd encourage you to take a look in the office of management and budget's rokus system which is where regulations are filed for review. there is a rule with a title referring to a final rule related to direct to consumer advertising pending at omb. >> thank you. >> thank you, senator. senator moran. >> secretary, thank you for being here. let me raise just a topic, and then i want to continue where senator blunt left off in regard to transplant program. i want to highlight for you that we have three hospitals in kansas, horton, hillsborough and as weeing go, small rural hospitals, all of them critical access hospitals. the thing they have in common, they're owned by empower hms. empower hms is, has been
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investigated by cms for billing fraud. but as a result of that and other factors, business factors, management factors, those three hospitals are in various conditions either shut down or have a trustee in bankruptcy attempting to operate those hospitals. and i would, first of all, encourage you to take -- not to change your enforcement procedures or not to any way pursue fraudulent behavior any less, but recognize there's a consequence to a community hospital that regardless of who the owner of the hospital is who can be gone that night, the community is left in a circumstance in which their hospital is no longer functioning. and so i would hope that cms and ores at -- others can have a plan in place that when you are creating a circumstance that forces a business out of business because of fraud, the end result is that the person who committed the fraud, the company who committed the fraud is who pays the price, not the
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community who no longer has a hospital. and i would welcome any thoughts that you or your folks at cms could provide in this particular case, but just generally there's a consequence for this bad behavior. and i hope that whatever bad behavior is determined if you determine that, that if appropriate, it's referred to the the president of justice. pause the -- the department of justice. because the consequences for this behavior is long-term generational consequences to communities and the people who live there. just of significant challenges now as a result of -- in addition to the challenges we just have of keeping hospital doors open generally in communities across kansas. in regard to the liver allocation issue, mr. secretary, let me ask just a couple of questions and then express my concern and dissatisfaction. let me first ask if you believe that enough is being done to help individuals with end stage liver disease who are not yet on the wait list.
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so there's another population, those who are on a wait list waiting for a transplant, there are those who are not on the wait list yet. is enough being done to advance their well-being? >> i think the number one thing that we can all be doing is working, as the chairman referred to it earlier, increase the supply of livers that we have for transplantation. that's the most important thing we can do to help with advancing individuals. i hope that we're doing everything we can with regard to care for individuals awaiting transplant. if there are things we could be doing differently, please do let me know. i'd want to make sure we're doing that. >> would you commit the department to a full public disclosure, a transparent public debate on this allocation, organ allocation transplant process? >> i'm happy to work with you on what that might look like. as i mentioned to the chairman, the challenge with this issue is that congress deliberately took
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that out of my hands to make it a non-political issue. and so when we don't like the conclusion, i'm fairly restricted in what i can do. but we certainly -- i believe the optm process was a public process with a public record but happy to work with you and your staff on any vehicle to insure that. >> mr. secretary, you're moving me to my complaining aspect by your comments. [laughter] because it was only after a lawsuit was filed, as i understand it, that this allocation process was then considered for change. and when you tell me that we constructed the ground rules for you to be removed from the process, you do a appoint the hrsa director. the hrsa director has written a letter to optm encouraging them to quickly implement the decision that they made and encouraging them. i would also tell you that while
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from time to time in this job people tell me something that doesn't always turn out to be true, but in our meeting senator blunt and i had with the hrsa director, the request was that we make certain that our constituencies -- transplant programs in our states -- submit not just comments, but please bring us a proposal because we're so interested in listening to the proposal. don't just complain about the proposal that's out there, tell us how to do it better. and i can tell you that the end result of our programs doing that, they were not considered. and, in fact, the decision was made before those comments were submitted, before that proposal was submitted by our constituents. and i quoted you, i wrote down what you said in a last minute or late, the computer program shut down because there were so many comments. the only lateness of our programs supplying their comments and proposals was
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because the computer was shut down because of commentary. and the decision was made before these were ever realize, and then they were approved with no changes thereafter. the original decision was made by the liver intestine committee and without ever seeing the comments of our constituents. and then secondly, it was approved immediately with no change even though you can claim -- perhaps correctly -- you can claim that the comments were then read a after the initial decision was made. my point is that while i'm often -- perhaps i misunderstand what has been requested of me or what my instructions are of how i can be a help to my constituents, what i think we did was exactly what we were told to do with no beneficial thing happening as a result of following those instructions. so this process has been flawed, and it is a flaw that arises out
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of the fear of a lawsuit. and after a long period of time -- i know what you're saying, chairman blunt -- [laughter] the policy in place was changed almost overnight in response to a lawsuit. and you're right, the issue is more organ donation, and the policy that is being developed is contradictory to what you said is the goal. i'll be back for the second round. >> senator merkley. thank you, senate moran. >> thank you very much. you mentioned that there's a big influx of unaccompanied minors crossing the border. and are you referring to people crossing between ports of entry? >> we will receive the 300-350 children from wherever they show up. if they show up at a border crossing alone, if they show up at a non-border crossing alone, their uacs, how they came across, or even if they were already a resident and come into federal authorities and they're unaccompanied alien children, they'll be referred to us no
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matter what, so i don't know where they cross the border. >> so they're in tijuana where you're saying that you can walk up to the port of entry and present themselves? >> if a child comes up to the border, presents themself and is a 12-year-old, a minor, and is an unaccompanied alien children, i believe at that point subject to whatever the rule of dhs are -- we'd have to ask secretary nielsen -- i believe if they're not immediately repatriate bl, they're sent to us. >> okay. so this is not the way it works, and i would encourage you to learn a lot more about this. right now if an unawe companied minor comes to the boarder in san diego, they are not allowed to present themselves at the border. everyone who is 18 and up is instructed to return to mexico to get into the book. this is the metering process. but if you're under 18, you're not allowed to get in the book, and you're not allowed to cross the border. so we are leaving these people
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permanently exiled inty wan a that with really no choice about how to proceed that's a good choice. if they present if themselves to the mexican authority, they're deported back into horrific circumstances. if they stay in tijuana, they're subject to gangs and sex predators that have a big sex industry there. and so their best option is to cross the border illegally. so while the president of the united states is telling the world don't cross between ports of entry, we're blocking the minors from crossing through the ports of entry. do you think that's acceptable? >> i do not know border -- >> well, i encourage you to find out. you're very directly affected by it. it's why so many miners are crossing between ports of -- minors are crossing between ports of industry. and the fact that you haven't educated yourself really is unacceptable. second, you said that you have sent a letter to congress to fund an expansion of the child prison system under this administration. what expansion level are you
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planning to go to? >> so we sent a funding and so we set a funding of reprogrammable request, not a request but basically a transfer message we were transferring $286 million using the million dollars using the 15% transfer authority and the reprogramming $99 million of money that is not needed for the refugee program within orr as part of a transfer and -- >> on top of the 266 million? >> at this current rate as a mentioned to the chairman that will not put adequate for this your. >> what is the capacity of the system usage with this money? >> that is supportive of our current rates ofs about 14,000 beds i believe as well as our expected added, trying to add as many six beds as a kid to care for them. you keep saying prison system. if you have an alternative approach to how to care for the children please tell us>> becaue
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-- >> let me explain it to you. >> we want to be compassionate -- >> you asked me. will have little dialogue. it's's called sponsors with the recess so hard to get sponsors as because administration is telling potential sponsors all l the information will be shared with ice, p therefore people to come for tod be sponsors becaue they don't be stuck in our criminal examination system. >> i believe congress passed and appropriations rider limiting usee of information that would o to dhs as part of the background checking that we have to do as part of our sponsorship checks. >> but, unfortunately, families are still being told that their information could be used in this capacity. so long as you're still telling families that, then they are discouraged spitters i'll be happy to look at that to see. i wasn't aware they're being told that. >> these children belong in homes and schools and parks, not locked up. i called in prisons because they
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are locked up. i don't know if you visited the system is but i have. did you understand what i'm talking -- >> i completelypl agree. i do not want any child in our custody. i want every child out with an appropriate. safe event sponsor. >> please examine the reasons why it's hard to recruit sponsors because that will facilitate --or it's costing a huge expense, temperate and flex a day for a pro-profit operator when a permanent facility cost much less and with sponsors it costs a fraction, just a fraction to have a caseworker to working with those families. not only is it much better for the children as they await an asylum process, it's much better for the american taxpayer. maybe it needs less profit for this for-profit companies are hard toin run homestead but shod watch out for the taxpayers and the children instead? >> i completely share your goal
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and my goal and the governments of goal that these children should be with sponsors and not in our care. >> a good. >> if we can work together to make that happen i will be delighted to work with anyone. >> they are in homestead in florida. they are not undertaken to address the child abuse and neglect checks for the staff members so they can make sure that the individuals they hire working with these kids do not have records as a sexual predator and that's unacceptable. >> senator kennedy. >> thank you, mr. chairman. thank you, mr. secretary. mr. secretary, do you believe in the rule of law? >> yes, i do. especially as a trained lawyer. i do, indeed. >> is it illegal to come into our country illegally? >> it is indeed illegal to come into our country illegally. >> okay. do you dislike children?
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want toe children i care compassionately for any child i'm ever entrusted with. >> are you trying to hurt children who are coming into our country at the border? >> not only that but i'm proud to lead an organization of people and grantees that are some of the most compassionate, caring child welfare people i have ever interacted with, who love these children and care deeply for these -- >> i read in march had about 100,000 folks, mostly from central america, mostly family units and children coming to america illegal across our southern border. does that sound about right? >> that's my information, it's about 100,000 coming across now in family units per month. it has created an absolute crisis. >> ten times more than, or double what it was i think ten years ago, something like that.
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let me ask you about the affordable care act. i remember when congress passed it. we were promised, we meaning i'm an american like you are, we were promised two things. will promise it would make health insurance cheaper, moree affordable. has it done that? >> no, it is not. we were promised that health insurance would cost half what it cost at the time. factoring resident obama's tenure at doubledin in cost for people having to bite. >> i remember vividly because i watched it on c-span. i remember congressd also promised us it would make health insurance more accessible. has it done that? >> no, in fact, it's restricted choice for individuals now with a large percent of states having one kerry in the individual market. >> let me ask you this. the president has expressed his disappointment with the affordable care act. does he support getting rid of it before we have a replacement?
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>> the president has always supported replacing the affordable care act with something else that is better. >> okay. let me be sure understand because there's been some innuendo here. does he support getting rid of the affordable care act without a a better plan in place? >> absolutely not. he insists there be a better plan in place. >> do you know of anyone on capitol hill, , republican or democrat, who supports a health insurance program or healthcare delivery system that would not cover pre-existing conditions? >> i haven'tov met them. >> does the president support a replacement plan for obamacare that would cover pre-existing conditions? >> he does indeed and he will never sent any other plan that doesn't take care of people with pre-existing condition. >> i want to look at the healthcare system from 30,000 feet. here's what i don't understand. i keep reading that 10% of the
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american people spend 67% of the healthcare dollars, which makes sense because we all know that the chronically ill spend more money than others. when you run the numbers, when youe' consider we have 320 milln people, really 330 million people, so 10% of that is 33 million people and we have $21 trillion, that's 12 zeros, gdp, and we spend 80% of that on gdp, and you take two-thirds of that 18% and then you divide it by 33 million, what you come up with is $80,000 a person. son for these 33 million people out of 333 million, we are spending about $80,000 a person. why can't we identify those 3-d
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3 million -- i didn't say 8000 -- 80,000. i'm going ton end this in time, mr. chairman. why can't we identify those people and with $80,000 a person manage their care better? >> you're right. in fact, we can't and we could do that through vehicles like either invisible or visible reinsurance pools. even under the aca i've approved seven state reinsurance plans that arero brought premiums down in the the state by anywhere fm 9%-30% by cleaving off the risk for those high-risk people and separately reassuring that so the burden is informed by all the other healthier people in that pool, absolutely. >> thank you. >> senator schatz. >> thank you, mr. chairman. thank you foror being here. i'm worried about tobacco use among our young people and that's why i'm about to introduce the tobacco to 21 act with senator young. our bill wouldou raise the minim
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age for making the 21 for the purchase of f tobacco products d that includes the sales combustible cigarettes and e-cigs. the institute of medicine has found raising the tobacco age of sales to 21 would reduce tobacco initiation especially among kids 15-17 and would lead to a 12% decrease in smoking prevalence, nine states including hawaii and hundreds of localities have already taken this action. do you agree that tobacco use among youth is a severe public health problem, and do you commit to me that we can work together on this legislation? >> thank you very much for the question and thank you for your work in this area. like you i'm extremely concerned about tobacco use and specifically the e-cigarette epidemic among our youth. i'm committed to working with you and with other members on legislation to address tobacco use among youth as well as take any necessary regulatory action.
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commissioner gottlieb is lasted a a day, and i've been very clear that whatle e-cigarettes may ofr a low-risk alternative for adult smokers who still want access to nicotine, we cannot allow e-cigarettes to be an on-ramp to combustible cigarette use or nicotine addiction for an entire new generation. fdal is proposing to prioritize enforcement a flavored e-cigarettes that offered for sale and was supposed a greater risk for minors acts of the products. fda will consider whether the products are sold under circumstances with a heightened age verification. while we pursue changes, we call on the industry, manufacturers and retailers, to step up with meaningful measure to reduce the access and appeal of e-cigarettes steer people. the epidemic level rise in youth e-cigarette use has prompted a series of escalating actions by the fda in both enforcement and public education. thank you very much for your help and i look forward to working with you on this. >> thank you. let's move to sell health.
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i know you're a big supporter of telehealth and that you noted the regulatory and payment barriers can limit telehealth services. one section of the connect for health act i would give you the authority to waive barriers to traditional medicare reimbursement under two circumstances. if the telehealth services would reduce spending while maintaining quality, or the telephone services would improve health care quality without increasing spending. can you talk about with the waiver authority wouldt mean in terms of public health and especially expenditures regarding public health? >> as you mention i've been passion in my advocacy of telehealth. it's vitally important for states like a wide, for states that are rural, for expanding access to care and expanding the quality of care where we have care delivery and to make sure all of america shares incidence of excellence through telehealth. the social security act was written in 1960s before
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telehealth existed, and so there are many barriers to that i look forward to working with you in any way to which greater flexibility could be brought to me in ways that don't open the door toe fraud abuse or waste of precious taxpayer beneficiary resources. >> this remains, we got a lot done with senator hatch is leadership and with a big bipartisan group on telehealth. there are a few more things to do. this is the only one but the waiver authority is the holy grail. for members, we have got to get this done. >> press this could be included in the work that senator murray and alexander are looking on cost work. >> and then just a final comment and a question i was struck by the exchange between senator merkley and you in one particular way. obviously i got contentious because frankly this is a kind of thing that should cause people to be emotional. to the extent that there's a statute that provides for
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confidentiality for potential sponsors, but in the moment where a decision is being made, sponsors are not aware of that statute. that seems to me to be a lightbulb went off for all of us, that we need to do a better job of communicating to sponsors that the coveted jelly is protected, that the situation is protectedly and that we, in fac, as a matter of government policy, whatever we think about the border wall, whatever we think about who's fault is what and what we ought to do with concert offices and all these other arguments, at a minimum these kids need sponsors and if the extent that potential sponsors are afraid to do so because they are afraid they're going to end up in some database, we need to do better job of telling them that there's a law that protects the confidentiality and i'm hoping we can work together to follow upor on that. >> thank you, of course. >> thank you very much. >> thank you, senator schatz. senator hyde-smith.
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>> thank you, mr. chairman. i y appreciate secretary azar being here today and answering the questions the way you are doing this. i obviously, the senator from mississippi, and we had m so may rural hospitals in mississippi that are really struggling. a recent report found that half of all rural hospitals in mississippi are at high financial risk of closing. i just read an article that mississippi has more rule rural hospitals at risk of closing and any other state this country. when a hospital closes, obviously the whole community is affected in so many ways. not only the employment, but mainly and what's most important, it means no more access to emergency care for the communitiesge residence. in an emergency, timely care is of essence. and having close by access to them can truly mean life or
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death. we just recently had a young lady in mississippi just a few weeks ago that died of an asthma attack. so i guess my question is, what is a just doing -- hhs doing to respond to these rural hospital closures that is very critical in my state? >> thank you. you've repeatedly raised with me the concerns about real hospital access in mississippi and in part because of your efforts, i have created ae task force acros hhs to look him up with all ideas that we can run how we can help address the hospital crisis. let me give you somesi ideas, oe of them were just discussing was telehealth, how going make sure expanding access into rural america. because we were in the console did everyone living in urban areas if he can't provide the health care in rural america. so telehealth is important. we have to make sure providers are able to practice to the maximum of their licensure so we're not having artificial restraints on trade and
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competition that are blocking access in ruralin america. we also to make sure that our regulations at cnas or otherwise are not creating artificial barriers to economically viable models of hospitals in rural america. are we trying to force the 1960s model of hospitals to our payment systems and h other regulations onto real america works we're looking at how to conceive the needs of rural america from hospital perspective can you set your fransen. i was talking with the lead of a critical access hospital yesterday i out of requiremente have which is to be -- at an surgeon on staff who might be 0 surgeries a year. one has to ask, does that requirement still hold in the modern era? does that a part of making the facility economically viable long-term to go toy but access n that community? this is as deep passion of mine. when working on this. any ideas you have to be
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helpful, certainly we want to be there. >> thank you very much. >> thank you, senator. senator baldwin. >> thank you, mr. chairman. secretary azar, i want to tell you about zoe from seymour wisconsin. so we was born with a congenital heart defect and ship actually open-heart surgery at five days old. she will be able to continue to get coverage and the care that she needs thanks n to the affordable care act and its protection for people with existing health conditions. when the republicans are working to repeal the affordable care act legislatively, i got a letter from zoe's mom, chelsea and chelsea were to and she said to me it's like they're taking the american dream from her,
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referring to her daughter zoe. she wrote, i'm pleading with you as a mother to fight for those with pre-existing conditions. kids in wisconsin with pre-existing conditions are counting on you to protect that right. the administration, your administration recently decided to support a lawsuit aimed at striking down the affordable care act in its entirety and all of its protections. so how do i explain a decision to zoe and her mom? zoe, by the way, just celebrate her sixth birthday, and this is more or less a rhetorical question because i'm asking specifics, but how do you tell a little girl like that what's going to happen to her? and so i just want to confirm my understanding that if the affordable care act is struck down in its entirety in court,
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position your administration supporting, what protections preventing insurance companies from discriminating against those with pre-existing conditions will still remain and law, if it's struck down? >> so of course there are the existing protections, hipaa protection from pre-existing condition that would not be impacted -- >> the marketplace insurance -- >> as iss mentioned with ranking member murray, we will be working with congress to ensure that -- .. president trump has broken his promise by expanding the use of
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junk health plans, that's what i call them because they don't have to cover pre-existing conditions. i want to share in wisconsin. one of the plans available from companion life. the very first sentence of their policy states, quote, pre-existing conditions diagnosed within 60 months-- the 60-month period immediately preceding the person's coverage date are excluded for the first 12 months of the coverage. another plan in wisconsin, quote, no payables for a pre-existing condition described as a condition that, quote, would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment within 12 months immediately preceding the date of coverage. so explain to me how this
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decision not only to join this lawsuit to try to totally repeal, overturn the affordable care act, but this decision to proactively expand the use and availability of these junk plans is not a broken promise to protect people with pre-existing conditions? >> so, i assume you're referring to the short-term limited duration plans which we restored to use that the obama administration had. these plans are not for everyone and they-- if a plan like that, and i'm quite glad the enhanced consumer disclosures that we have made it apparent if you had a pre-existing condition those are not plans you should choose. you would be getting an exchange based plan or-- >> you're arguing in court to overturn the affordable care act so there won't be a marketplace. now i want to move on to something that you and i have discussed at length, which is
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drug prices. if the administration is successful in the lawsuit and the affordable care act is struck down, the laws prescription drug price enforced will be done. your prescription drug proposal would be wiped out because your own pilot program is being tested through the center for medicare and medicaid innovation, cmmi, which was created under the affordable care act. so, yes or no, mr. secretary, if lawsuits-- if the lawsuit succeeds and the affordable care act is struck down in court, cmmi will cease to exist and so will this pilot. is that true or false? >> there are a great deal of if's in there, but the cmmi is part of the affordable care act and my hope is any better health care we set up would give me the authority to pilots and firmly committed to there-- >> so to exist-- >> we would have to find
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additional authority. >> thank you, senator. thank you, mr. chairman. thank you, mr. secretary, for being here. my first question from the state of west virginia, and senator manchin and i have been lucky enough to be on the committee have been ravaged by the opioid epidemic and we're feeling the ripple effects, and you note add increase of hep-b and c and hiv. and can you talk about how you've worked with the state and some have been forward-leaning in trying to master there. >> first off, the ending hiv will be focused-- 10% of hiv cases are coming out of injectable drug use. the efforts there, we hope we will stop the spread of hiv in this country, would tackle that.
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in addition special funding as part of the budget and the opioid initiative that we've requested to help with hiv spread and infectious disease spread connected to the opioid problem that we have in the country. >> well, in my conversations with the head of the c.d.c. recently, he did tell me that with the new availability of different metrics you're able to identify clusters quicker and be more effective with that. so, that's very important to us. i'm going to shift to another issue that i'm very passionate about and that is senator reed and i, he's a member of the subcommittee as well, work together to pass the star act, which is the childhood cancer survivorship treatment access and research. we got $30 million in the budget for that. i'd like to know what your department is doing on that and where you think it will lead to? >> first, thank you for your support in the star act and getting that passed. we've already begun implementation at the national cancer of the nci specific
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sections there. and one of the most important issues are enhancing the biospecimen collection and biorepositories aid us in the focus on pediatric cancer and that's vital for building the evidence base and information we need. and also to continue and conduct and support childhood cancer survivorship efforts at c.d.c. we're working on the c.d.c. cancer registry is there so we'll look for their continued successful early case capture program that lets us identify children right away. so that also helps us with the research program by getting that type of information and making that available. >> so does the budget reflect a next -- next year a continuation of that funding? >> as you know, our budget proposes addition al $50 million to nih for the 500 million 10-year program on
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pediatric research. pediatric cancer has been neglected for a time. >> right, i knew that. >> thanks to the star act, thanks to the president's initiative on pediatric cancer, we'll get a focus there. >> i hope so, too. and some of our leading research hospitals in our state are putting a great focus on this. last i will, i'd like to ask you another thing that-- a statistic that i found rather surprising because i don't think we think of ourselves like this as a country, but the rising statistics of maternal mortality, and i think you're quoted in your statement saying over 700 women died in and around associated with childbirth. we did pass with a bipartisan effort a maternal-- maternal mortality accountability act for us to get good statistics on what's actually going on here because you state that these deaths are
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actually, many of them, very preventible. what steps is your department taking to take charge of this issue? >> well, as you mentioned, maternal mortality rates in the u.s. more than doubled over the few decades. >> do you have any idea why? >> prenatal care and access and in rural america we have a labor and delivery crisis and associated with that appropriate prenatal care and of course the immigration crisis is bringing in so many individuals in terms of getting adequate prenatal and labor and delivery care, also. i don't know the full demograph elk bre elk-- demographic breakdown, but i appreciate senator murray on this. and budget dollars for the maternal suffers at c.d.c. >> right. >> you just mentioned, including $12 million to collect data and research, understanding better the causes of these deaths so we can really aim at the problem and
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tailor solutions toward that. >> i think you'll find both senator murray's leadership and others, you'll have a very supportive senate and probably congress in this effort. obviously, the president supporting this as well. thank you so much. >> thank you. >> thank you, senator capito. senator murphy. >> thank you mr. secretary for being here today. i want to thank the chairman and ranking member for acknowledging at the outset what is the reality here, this budget is not going to be reflected in the one that congress ultimately passes. we would never support the kind of draconian cuts that are in it to people in need, to very sick people, to very vulnerable populations and so i understand that we are going to work together, republicans on democrats to make sure that this budget never ever sees the light of day, but i think for the good of the order, it makes sense to repeat why this budget is so offensive to many of us. it's not just the cuts, it's
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that they stand in contrast to a giant gift wrapped present that this congress gave to the very, very wealthy in this country about a year ago, a 2 trillion dollars unpaid for tax cut that was promised to increase wages for $4,000 per person. that simply has not done that. it when fully implemented will deliver 80% of the benefits to the top 1% of income earners and we're seeing who is asked to pay for it. frail citizens in connecticut who are going to have their heating shut off because the trump budget tonight go to the assistance heating program. that's at the heart of our frustration, it's not just that this budget doesn't reflect our values, it stands in contrast with a tax cut that just is not going to deliver results for the majority of americans. mr. secretary, i wanted to talk to you about the effect of this budget on the opioid epidemic.
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if your testimony you point to about $5 billion in funding that is directly dedicated to the opioid epidemic, money that's largely in the budget. it stands in contrast to 1.5 trillion in medicaid cuts in this budget, including the wholesale elimination of the medicaid expansion. four out of ten non-elderly adults that are dealing with opioid addiction today are on medicaid. and so when you put $5 billion in essentially flat funding for specific ipo treatment, next to 1.5 trillion dollars in cuts to the insurance program that actually allows states to pay for treatment, the result is a devastating net negative. a dramatic contraction of federal dollars out of the opioid treatment system and i guess i just want to be honest what we're doing here. i know you may say, well, we're
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still going to spend more money in real dollars, but this is a $1.5 trillion cut compared to what we expected states to spend and i feel like we should just be honest, what this budget asks is for states to pick up a much bigger share of the burden for caring for people with addiction. and that this national emergency we declared comes with it an expectation that the federal government would do less and states will do more. connecticut will try to scramble to come up with the money when we lose 11-- 100,000 people off the rolls of the medicaid program. and i want to ask you that, aren't we asking states to essentially pick up the burden of the opioid epidemic, giving comparisons of the medicaid cuts in this bill to the $5 billion in specific opioid
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funding? >> i don't think so. well, you're right, we have a $1.5 trillion reduction that's in the budget for the medicaid expansion and the affordable care act exchange subsidies. we add back 1.2 trillion dollar program that would be state-based flexibility. my hope is that would actually correct. one of the things i worry about the opioid crisis and many other public health issues we deal with, is that the medicaid expansion focused on able-bodied adults, incentivized away from children, pregnant mothers, those opioid addicted part of the core medicaid. my hope is with the $1.2 trillion program and flexibility for the states on that money, that they would focus that in areas like you just talked about where the needs are greatest. and really prioritizing those areas and might actually enhance coverage and access for those individuals that we all
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care so much about. >> yeah, we've heard this for a long time, flexibility will allow states to enhance and greater focus their coverage, but in the end, it's a whole lot less money than they were getting today, and states are begging for additional dollars to care for people with opioid epidemic, asking them to just focus better with less money, i think ignores the feedback that all of us are getting, republicans and democrats, about the realities on the ground. thank you, mr. chairman. >> thank you, senator. senator manchin, followed by senator shaheen. senator manchin. >> thank you, mr. chairman. thank you, mr. secretary, and for your service. you and i talked briefly. i'm if asking for the help we need in our little state of west virginia. we face the largest per capita in the country and i think my friend senator shaheen is right there behind us.
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it's costing our little state 8.8 billion a year and focusing the largest share of gdp of any state cost related to the crisis, 12%. i appreciate what you all have done and everybody's concerned about the cutting. i think we'll work through this, okay? but the 15% set aside that you have for hard-hit states, i'm asking through your rules and regulations if you can do this. you have to take into consideration the deaths per capita, not just the total death. like on counties it's enormous. but if you look at the total deaths and offsetting the 15% we can't help them that much. does that make sense? >> there's a lot of sense to that and i appreciate your raising that issue. one thing would be where-- and you all helped a lot with the support at with-- not just the support act, but with your appropriations funding on opioids, helping us to focus money on the highest burdened states.
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if that issue of death versus incidents per capita is in there, i'd ask you to fix that. >> we can and-- >> and there may be allocation issues within the state. for instance, rural versus urban within the state, happy to work with you and the government in west virginia to educate and focus on that area. >> okay. two quickly and then my final comment. jessie's law, we talked about that and you might want to expand on what can be done, how quickly you can make this happen. i know there's some hoops that we have to jump through, but all of us agree that jessie's lawyer is something extremely needed and can save lives. and it's so simple, but, yes, we're running into complications as far as privacy and hipaa. those type of things. >> thank you, and thank you for prioritizing the work in this area and i am going to be speaking with the head of the national coordinator, as well as samsa and the best practice as part of the jessie's laws
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support act. we have to examine 42 cfr part 2 to make sure there aren't unintended consequences, where providers don't put information about somebody's addiction status in the electronic medical records for fear of additional regulatory complications there. so we need to make sure and make sure it's not standing in the way of appropriate care and treatment. what happened to jessie shouldn't have happened. >> i appreciate that and it means so much to all of us. quickly, funding for this horrible, horrible disease of addiction. i've introduced life boat year after year after year life boat basically says all pharmaceuticals producing op open-- opiates, that's a heavy lift for some of my friends. that's not a tax. if you think we need these products, pay a production fee
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and let us make sure that we have a constant stream of money that goes to the area hit the hardest. >> you know, the genesis-- >> it won't put anybody out of business. >> the genesis of this crisis were the legal opioids. and i'm glad we've got it down to 20% and the-- >> you can at that about this, this would be a great life boat act, one penny per milligram would be tremendous help. >> the affordable care act, the president says he's not doing anything until after 2020. let's suppose the courts advocate this, you have a lot of expertise. and you've got it on the table, how would you fix anything on the table nothing new, not inventing the wheel. i wasn't here in 2000, and hard pressed to vote to change a few things. what we have is integrated into our system, one-sixth of our
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problem. how would you fix the problems? >> i believe there are deep problems in the aca and how the insurance benefit is structured there, issues around-- i'll give you within example, which is the three to one rating. essentially you've made insurance for individuals who are healthy and young, say, unaffordable and they walk from the market and that created this kind of downward spiral that you're seeing-- >> you're saying because we're preventing higher than a three to one rate that are on people who are very sick. >> right. >> that's where our difference it. our republican friends cannot come up with how do you protect preexisting conditions. >> we're going to make it illegal for anyone, any insurance not to sell and that by definition, you said they can't deny pre-existing condition. and you can charge us out of the market and i can't afford it and my aunt can't afford it and it will break the family and they go back out.
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back home in west virginia, they'll say i don't want to be a burden to my family. that means they can't afford what's out there. you're not preventing them from being denied, but preventing them to afford it. >> there are ways to make sure that insurance for people's pre-existing conditions is affordable and senator kennedy and i had a discussion about reinsurance vehicles, very, very actually quite well-established and working well. we have a bill called collins-nelson and i'm announcing that since bill is not here. we'd love your support on that because we think that would be a big fix in reducing from the private pay because from 20 to 40% overnight. >> we'd be happy to work with you on that, especially if we could do that in conjunction, as we have before with what was going to be the alexander-murray-collins-nelson package. >> those two bills have been laying on chairman--
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on majority leader mcconnell's desk close to two years. >> we'd be happy to work with you on those. i think where we've got a stumbling block, senator murray, around ensuring the funding on the csr's would have appropriate hyde act protections. and i think that's the stumbling block. >> if you want to stay for a minute. there will be time for more questions if you have more to ask. senator shaheen. >> well, thank you, mr. secretary for being here. i would say that there's actually an agreement between both sides on the alexander-murray legislation and a strong list of bipartisan sponsors and it's unfortunate that because there was opposition from the white house, because there was opposition from the leadership in the senate, that that bill wasn't able to come to the floor. and i would encourage you-- i think everybody who has been in the senate since we passed the affordable care act recognizes that we need to
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improve some things, that some things are not working, but the response is not to refuse to come to the stable. it's not to overturn the law so that people have no alternatives. >> the answer is to work together to get it done and i'm very disappointed that we have not seen that kind of leadership either from the senate leadership or from the white house. so i hope you will share your views that you think there are things we could do together because so far that's been missing from the conversation. i want to just agree with senator manchin of the importance of the set aside on the opioid funding. it has been critical in a state like new hampshire where, as you know, because you're familiar with it, we have a huge problem. we are behind west virginia in terms of the overdose death rate, but way too high for our state. we have way too many families
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who are affected and the pain is-- you can't talk to anybody in new hampshire who doesn't know someone or hasn't had-- been affected personally by this epidemic, and those set aside dollars that have been used for the state opioid response grants have made a huge difference in new hampshire and allowed us to set up a hub and spoke system that keeps people within an hour from a place where they can get treatment, which has been very important. we're still waiting to see exactly how this is going to work, but it's an improvement and something that would not have been done without those dollars. we had a hearing here a couple of weeks ago, and i was talking to you about it at the start of this hearing where there were people from states across this country who were directors of programs to respond to the opioid epidemic and i asked them all a question. one was from new hampshire. she had the recovery center.
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i said what happens if these federal dollars go away? and she said, well, i'll go back to bake sales. the other-- some of the other folks were a lot more direct. they said people will die. and in new hampshire the expansion of medicaid has been one of the things that has been most critical to ensuring that people can get treatment and that we can prevent some of those deaths. and yet, i share the concerns that senator murphy was raising about what this budget does to repeal the medicaid expansion and replace it with block grants. not only does it cut the amount available to states, but it assumes then every state is going to come up with the funding to replace that and i think that's a huge question in a lot of the country. so, can you talk about what we should say to those people who are running the programs to
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address the ipo epidemic about why they -- what they should do if these federal dollars go away? >> well, i appreciate your concern. the president is adamant, our budget reflects this, about the funding and support for the opioid epidemic and work to ensure the states with the highest burden are getting the share of resources they need to deal with this. in addition, our budget proposes with medicaid that we would actually expand access for women postpartum for one year, have eligibility postpartum who are suffering from addictions. that's one of the changes we've got in the budget. we continue to process the imd exclusion waivers to ensure that we have capacity and expanded patient for the community. we're fully engaged and fully
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focused around the opioids. and we're helping to really expand capacity by making it quite clear that this is the most evidence-based approach to people for treatment and lifelong recovery. >> well, he appreciate those changes. i think they're very important, but if the fundamental funding source and coverage source for people to get treatment goes away, then those are-- those will make a small difference, but they won't address the underlying problem. i would like-- can i ask one more question, mr. chairman? >> yesterday a study from the keiser family foundation found that medicare part d spending on insulin grew 480% between 2007 and 2017. as you know, diabetes is one of
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the most chronic illnesses we have in this country and figuring out how to help patients with the cost of insulin at the pharmacy counter is critical, but it's also a question about how can we be most effective with our public dollars to address illness. so i know that your department has proposed new rules to limit the impact of pharmacy, benefit manager rebates that helped to drive up the cost of part d drugs. can you tell us whether you think removing that link is going to help address things like those insulin costs or do we need to be doing something else? >> well, i would defer on the something else. i can tell you that the rule that we have proposed to get these rebates out of the system and instead have those go as discounts to the patient at the pharmacy level, would be revolutionary for the patients in the situation that you're talking about, especially classes like insulins, or
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arthritis medicines or high cost cholesterol medicines that are very highly rebated now. you might have in some of those classes, average 70% rebates. imagine january one of 2020, when that patient walks in the pharmacy if this rule goes forward, they will get a 70% discount every time that fill that prescription. it's a revolutionary change for patient access and affordability if we can get this through and i pray that we'll have your support to help do that. it's $29 billion of rebates going to pbf and pharmacy managers now that would go to patients starting january 1, 2020 if we can make that happen. >> i look forward to hearing more about it. >> thank you, mr. chairman and for allowing us to ask one more question. mr. secretary, i did want to express serious concerns about what's going on in the unaccompanied children's
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program. most shelters are working to provide excellent care to this program. hhs as you know, is charged with the welfare of every child in its care and i am deeply troubled by some of the reports of forced drugging, sexual abuse, substandard conditions at some of the temporary facilities and i was especially appalled by the great lengths that former oor director scott lloyd went to prevent minors in orr custody from accessing reproductive care, including where pregnancies were the result of sexual assault. despite the fact that the judge issued an injunction barring orr, a recently released spread sheet showed that orr continued to track minors private reproductive health information through june 2018 and there's no indication that the information collected in that spread sheet is being used to
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ensure access to reproductive care. i wanted to ask you, does orr still keep a spread sheet containing the reproductive health information on pregnant minors? >> i'm not aware of any centralized spread sheet. i believe-- i could not answer for him. i believe the intention-- this was the last menstrual period date, which of course for any of us who have had children know is vital to prenatal care to know gestational age. child, not ongoing cycle information or otherwise, that is my understanding. i'm not aware whether there would be-- and i doubt there's any type of sentry repository. we've actually ensured now the delegation from the orr director of all decisions on significant medical procedures for unaccompanied alien children to the orr career staff and i believe we're fully compliant with the court's order and injunction and faithfully executing on that. >> well, what are you doing to make sure that orr complies
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with the court order? >> i have and always will make clear when there's a court order in place we are to faithfully apply that. so the order you're referring to, i believe we're in full compliance. if we're not, i'd like to know. we should always be in compliance with orders. >> and when were you aware that mr. lloyd was briefed on minors health information and contacting pregnant minors to keep them from seeking abortion. do you believe that's an appropriate role for the director and when did you know? >> i think you and i spoke about this during the confirmation process, if i remember correctly, back in my first hearing in early december before i was in office, so i think probably this was an issue of some controversy even then, public, public controversy. so, i think probably around then, goodness, i can't quite remember. listen, the issue of a 12-year-old girl who is
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pregnant in our care, we are-- we're the custodian of that child and we are delegate today make serious medical decisions as the parent of that child, but in consultation if we can with the parents. >> okay. >> of that child. >> this is really important information and senator feinstein and i sent last week a letter to you asking you to have your staff brief us fully on what you were doing, where that information is, and how it's being used and would like you to commit to having-- >> we'll certainly work with you on that, absolutely. >> thank you. >> thank you, senator, i have two quick things, there will be more for the record, i'm sure, but one is we're nearing the end of the two year pilot period of excellence in mental health. not my goal or senator stabenow's goal, i don't believe, for the federal government to be a permanent sponsor of that effort of treating behavioral health like all other health, but it is our goal to come up with all the
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information we can about the impact of treating behavioral health like all other health and what's the impact on other health costs. so my request to you, as we talk about maybe a two-year extension to just get more information for states to look at in the future. be very helpful if you could commit to provide us any early cms data before that program expires. >> i'll work with the administrator to get you any information we have, data to help support the analysis of your legislative-- to support that legislative effort. >> you understand what i'm saying, if you have early data. >> yeah. >> to show one thing or another here, it would be helpful for us to say, we believe this is where this is headed and we'd like to compile a little more information and the goal here, again, is not for the federal government to make behavioral health, their health
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responsibility, but put the information out there that shows not only is this the right thing to do, which everybody already knows, but it's the fiscally smart thing to do as well. and my other question on the sponsor criteria on the unaccompanied children that you talked about, who sets that sponsor criteria in terms of what the sponsor has to-- has to provide and how that is shared or not shared? is that you or is that homeland security? >> so, it would be statute as well as us. so, the sponsor ship criteria are set in the-- i believe it's the trafficking victims protection act. largely categories of one, two, three, four sponsors, our preference is always a category one sponsor which would be a parent or guardian here in the united states already that we can place them with. then category 2 would be our
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other relative aunts, uncles, brothers, sisters, that we would place them with and then three would be more distants-- distant relatives that we could place. there are certain mandates in the statue, where there are red flags, home visits and home inspection. we always have the right to do fingerprints and biomed-- biometric checks. we've had heightened requirements in part driven by -- if you remember your colleague on the permanent subcommittee on investigations did some work, senator portman and senator carper, on children who got placed with traffickers or ended up with traffickers in ohio at the egg plant. so, it's always a balance. we want to make sure we're balancing keeping children in care as short a time as possible, but also making sure
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when they're placed out, we're placing them into a safe environment. so we're always assessing any discretionary aspects of that balance, to strike that. so we have required fingerprints of all times on say, household members for a level two sponsor. we decided in december that that wasn't -- that we weren't seeing enough hits there in terms of information, added information, that that was automatic, that that merited the delay from people coming in as unrelate-- as these household members, and so, we've pulled back on that. we're always assessing what the needs are. >> i believe in your earlier response to senator merkley, you said you believed your direction from the congress was that that information is not to be shared with the immigration service. >> no, no, if i could clarify. that information is shared with
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immigration, with immigration so we can confirm identity, do background checking or-- and also get immigration status. we have long, previous administrations included, gotten immigration status. that's part of our placement decisions. not that they're precluded-- but if they're about to be deported they're not a long-term support for someone-- >> if you find someone is illegally in the country and not about to be deported. what do you do? >> we still place-- if the person is within the categorization of sponsors an appropriate sponsor from the child welfare perspective, we place the child. and most are placed with people probably illegally in the country. at dhs, there was an appropriations rider, passed as part of the large budget deal to end the closure of the
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government that actually restricts the use of that information over at dhs, but i'd have to refer to dhs and its lawyers on that question. >> thank you, secretary. senator moran? >> i'll attempt to be brief, mr. chairman, thank you for the second round. mr. secretary, i want to highlight, i mean, i would -- you and i would agree this is a significant issue affecting liver transplants, this policy has consequences and it's significant, true. >> correct? >> yes, the issue of liver transplants are very important to all of us, absolutely. >> and i got involved or interested in this topic after a conversation with liver transplant program in my state, but as a result of that activity, i've been amazed at the number of people, individuals in kansas and elsewhere, who come to me to talk about the importance of this liver transplant policy. people who have had a liver transplant, people who are waiting for a liver transplant.
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people who want to be on a list for a liver transplant, and again, you and i both would highlight and use this opportunity to highlight the importance of people being organ donors. we need more organs to meet the demands, but this is not just about the consequences to a particular transplant program. this issue has significant consequences, and in fact, life and death consequences for people across the country. and finally, i would remind you that senator grassley, along with almost half the senate, sent a letter to you which i don't believe, at least i've not seen a response and i would encourage you to respond. >> thank you, and i do want you to know that i take that letter seriously. it has my personal attention and prompted me to ensure that we went to optm to ask them to think again and to ensure the full consideration of comments out of kansas and missouri
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providers. that was, in spite of the computer glitch and i understand the process here was that, okay? in terms of the interactions would you and on behalf of the department, i apologize to you for any lack of courtesy and also, just any problems in that process. my understanding is those comments, in spite of the computer glitch, were summarized to the optn board in their decision making and at least the summaries part of the original decision making and presented in full of the committee later, i understand that is not necessarily everything that want to hear in terms of, it would have been nice if they had been presented in full, at, before any initial presumptive decision was made. and that's why i went back and said, please think again. please, you know, look at these comments. look at these concerns. obviously, they've got tremendous respect for every signatory on that letter. and i can only-- and i hope if you don't have it, we'll get it to you.
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the letter of response that i got. and if there are further avenues that are appropriate, legally justifiable to assure appropriate consideration. >> i've not been discourteously treated, but i failed to get the results i'm looking for, even courteously treated and it's results i'm looking for on behalf of folks who desperately need a liver transplant-- >> thank you secretary azar, the record will stay open for one week, and the subcommittee stands in recess. [inaudible conversations] [inaudible conversations]
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